<form action="" class="form-inline formDatLk" style="margin-bottom: 0;">
    <table class="tableNone">
        <colgroup>
            <col width="150"/>
            <col width="210"/>
            <col/>
            <col width="140"/>
        </colgroup>
        <tbody>
            <tr>
                <td>
                    <label>Họ và tên:</label>
                </td>
                <td>
                    <div>
                        <input type="text" name="full_name" style="width: 180px;" />
                    </div>
                </td>
                <td colspan="2">
                    <div>
                        <label style="margin-right: 10px;">Tuổi:</label>
                        <input type="text" name="age" style="width: 25px; " />

                        <label style="margin: 0 10px;">Giới tính:</label>
                        <label class="radio">
                            <input type="radio" name="sex" id="sex_1" value="1" checked="checked"/> Nam
                        </label>
                        <label class="radio" style="margin-left: 10px;">
                            <input type="radio" name="sex" id="sex_2" value="2"/> Nữ
                        </label>
                    </div>
                </td>
            </tr>
            <tr>
                <td>
                    <label>Địa chỉ:</label>
                </td>
                <td colspan="3">
                    <div>
                        <input type="text" name="adddress" style="width: 502px;"/>
                    </div>
                </td>
            </tr>
            <tr>
                <td>
                    <label>Số điện thoại:</label>
                </td>
                <td>
                    <div>
                        <input type="text" name="phone" style="width: 180px;" />
                    </div>
                </td>
                <td>
                    <label>Thời gian yêu cầu khám:</label>
                </td>
                <td>
                    <div>
                        <input type="text" name="date_require" class="form_datetime" style="width: 134px;" />
                    </div>
                </td>
            </tr>
            <tr>
                <td>
                    <label>Bác sĩ yêu cầu (nếu có):</label>
                </td>
                <td colspan="3">
                    <div>
                        <input type="text" name="doctor_name" style="width: 180px;" />
                    </div>
                </td>
            </tr>
            <tr>
                <td>
                    <label>Nhập mã xác thực:</label>
                </td>
                <td>
                    <div>
                        <input type="text" name="captcha" class="text" style="width: 180px;" />
                    </div>
                </td>
                <td colspan="2">
                    <img src="images/sample_captcha.jpg" style="height: 26px;"/>
                </td>
            </tr>
            <tr>
                <td colspan="4" style="text-align: center; padding-top: 10px;">
                    <button class="myBtn myBtnNormal" type="button">HOÀN THÀNH</button>
                </td>
            </tr>
        </tbody>
    </table>
</form>

<script type="text/javascript">
$(".form_datetime").datetimepicker({
    format: 'dd/mm/yyyy hh:ii',
    minuteStep: 15,
    language: 'vi',
    weekStart: 1,
    autoclose: true
});
</script>